SIMS Foundation, Inc. P.O. Box 2152 Austin, TX 78768
Confidential Numbers: Phone 512-494-1007
SIMS AGREEMENT FOR PSYCHIATRIC PROVIDERS
I, ______________________________________________, agree to be a provider of
psychiatric services for the SIMS Foundation, Inc.
* I understand that SIMS is a 501(c)(3) (non-profit) organization and that I am not
providing services as an employee of SIMS.
* I agree to abide by all of the terms and conditions provided in the Policies for SIMS
Psychiatric Providers, which I have read and understand.
* I agree at all times to maintain my professional licensure and liability insurance in
accordance with the Policies for SIMS Psychiatric Providers.
* I agree to uphold the ethics and standards of the licensure under which I practice.
* I further understand and agree that my compensation for the services I provide will be
as stated in the SIMS Psychiatrist Services Fee Schedule shown below.
SIMS PSYCHIATRIC SERVICES FEE SCHEDULE
Category of Visits Patient Co- SIMS Co-Pay TOTAL
Initial Psychiatric Co-Pay from $25 Balance remaining after $125
Assessment (APRN) to $40 client co-pay
30 Minute Medication Co-Pay from $25 Balance remaining after $62.50
Management (APRN) to $40 client co-pay
Initial Psychiatric Co-Pay from $25 Balance remaining after $200
Assessment (MD) to $40 client co-pay
50 Minute Medication Co-Pay from $25 Balance remaining after $150
Management (MD) to $40 client co-pay
Emily Rudenick, LPC Signature of Psychiatric Provider
SIMS Clinical Director
SIMS Agreement-Psychiatric Providers 10-09 .doc Page 1 of 2
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